Retrieval of Additional Epinephrine from Adrenaclick-Style Epinephrine AutoinjectorsAnaphylaxis is a life-threatening allergic reaction involving multiple organ systems that can result in significant morbidity and mortality if left untreated. Epinephrine is the mainstay of treatment. Most episodes of anaphylaxis resolve after a single dose of epinephrine, but biphasic and protracted courses of anaphylaxis are well described. The need for additional doses of epinephrine poses a significant challenge in the wilderness setting, because patients and providers may only carry a single autoinjector.
Acute Hamstring Muscle Tears in Climbers—Current Rehabilitation ConceptsAcute hamstring injuries are often caused by the heel hook technique. This technique is unique to climbing and causes injury to muscular and inert tissues of the posterior thigh. The heel hook is used by climbers during strenuous ascent on overhanging walls and when crossing difficult terrain. The technique reduces the amount of upper body strength required during strenuous climbing because the climber’s center of mass is retained within the base of support. The heel hook is stressful collectively for the hamstring muscle group and musculotendinous junction.
Physiology of the pituitary, thyroid, parathyroid and adrenal glandsEndocrinology is the study of hormones, endocrine glands and related diseases. Understanding basic hormonal physiology is essential for surgeons to manage patients with endocrine disorders. In this article we present the fundamental physiological mechanisms related to pituitary, thyroid, parathyroid and adrenal hormonal production, secretion and action. Moreover the methods used in the investigation for hormonal disturbances associated with these glands, resulting in excess or deficient secretion, are introduced.
Implementing Wilderness Medicine Training for Undergraduate Medical Students in the UKThe UK General Medical Councils’ approved curricula share only 3 topics with the Fellowship in the Academy of Wilderness Medicine core curriculum, suggesting an underrepresentation of wilderness medicine (WM) in medical education. We developed a 5-mo course to address the gaps between these curricula to run in parallel with the conventional curriculum. Our 71-h course is composed of lectures and practical exercises. We set out to evaluate the effectiveness of this concept and assess its suitability for use by other institutions.
Fresh Low Titer O Whole Blood Transfusion in the Austere Medical EnvironmentMassive hemorrhage is an immediate threat to life. The military developed the Tactical Combat Casualty Care guidelines to address the management of acute trauma, including administration of blood products. The guidelines have been expanded to include low titer O whole blood, which is in limited use by the military. This proposal describes how the transfusion of fresh whole blood might be applied to the remote civilian environment. In doing so, this life-saving intervention may be brought to the austere medical environment, allowing critically hemorrhaging patients to survive to reach definitive medical care.
Emergency Medical Training for the Commercial Fishing Industry: An Expanded Role for Wilderness MedicineThis article describes the conception, implementation, and evaluation of a wilderness medicine–based first aid class for the commercial fishing industry. Commercial fishing is a dangerous occupation in the United States. Currently, commercial fishermen often only have access to basic first aid classes. Because of its focus on austere environments, hazardous conditions, and distance from definitive medical care—hallmarks of commercial fisheries—wilderness medicine offers a more appropriate approach to decreasing morbidity and mortality in the industry.
An Experience of Improvised LaryngoscopyAirway management in the wilderness runs the gamut from basic airway support to endotracheal intubation. Fortunately, direct laryngoscopy is a seldom called upon skill in expedition medicine. However, the medical skills required during a mission or expedition are never truly known in advance. Improvisation during evolving medical events is a mainstay of expedition medicine education and practice. It is unlikely, given constraints of weight and size of expedition medical kits, that a conventional laryngoscope would find its way into a standard “go bag.” Faced with the real but rare event of needing to intubate a patient in an austere environment, how can improvisation be used? Multiple ideas for improvised laryngoscopes can be found in the wilderness medicine literature, but which, if any, of these devices have true clinical utility? To this end, participants of a recent Wilderness Medical Society preconference in medical elements of light search and rescue were given the opportunity to devise and construct their own improvised laryngoscopes and attempt intubation of a training mannequin.
Core Content for Wilderness Medicine Training: Development of a Wilderness Medicine Track Within an Emergency Medicine ResidencyWilderness medicine training has become increasingly popular among medical professionals with numerous educational opportunities nationwide. Curricula for fellowship programs and for medical student education have previously been developed and published, but a specific curriculum for wilderness medicine education during emergency medicine (EM) residency has not. The objective of this study is to create a longitudinal wilderness medicine curriculum that can be incorporated into an EM residency program.
The Provision of Prescription-Only Medicines for Use on UK-based Overseas ExpeditionsExpedition teams without accompanying medical professionals traveling overseas from the UK frequently carry medical kits containing prescription-only medicines (POMs). Access to safe, basic POMs whilst on expedition is important, as the quality and availability of medicines in-country may not be acceptable, and delay in treatment may be hazardous. At present, there is no published guidance relating to drug acquisition and administration in these situations. In the UK, a number of different practices are currently in use, with uncertainty and medicolegal concerns currently hampering safe and efficient provision of POMs on overseas expeditions.
How To Teach Emergency Procedural Skills in an Outdoor Environment Using Low-Fidelity SimulationTeaching emergency procedural skills in a wilderness setting can be logistically challenging. To teach these skills as part of a wilderness medicine elective for medical students, we designed an outdoor simulation session with low-fidelity models. The session involved 6 stations in which procedural skills were taught using homemade low-fidelity simulators. At each station, the students encountered a “victim,” who required an emergency procedure that was performed using the low-fidelity model. The models are easy and inexpensive to construct, and their design and implementation in the session is described here.
Medical Planning for Extended Remote ExpeditionsRemote extended expeditions often support scientific research and commercial resource exploration or extraction in hostile environments. Medical support for these expeditions is inherently complex and requires in-depth planning. To be successful, this planning must include substantial input from clinicians with experience in remote, emergency, and prehospital medicine and from personnel familiar with the proposed working environment. Using the guidelines discussed in this paper will help ensure that planners consider all necessary, medically relevant elements before launching an extended remote expedition.
Heat Stroke Risk for Open-Water Swimmers During Long-Distance EventsOpen-water swimming is a rapidly growing sport discipline worldwide, and clinical problems associated with long-distance swimming are now better recognized and managed more effectively. The most prevalent medical risk associated with an open-water swimming event is hypothermia; therefore, the Federation Internationale De Natation (FINA) has instituted 2 rules to reduce this occurrence related to the minimum water temperature and the time taken to complete the race. Another medical risk that is relevant to open-water swimmers is heat stroke, a condition that can easily go unnoticed.
Participation of Iatrogenically Coagulopathic Patients in Wilderness ActivitiesAn increasing number of patients routinely undergo long-term anticoagulation with warfarin or other pharmacological agents. There is little evidence and no consensus documents in the literature regarding the appropriateness and relative risk of their participation in wilderness activities. We present a case report, conduct an analysis of the limited literature that is available, and make recommendations for wilderness medicine practitioners and screening personnel.
Contact Dermatitis From Eriodictyon parryi: A Novel Cause of Contact Dermatitis in CaliforniaAllergic contact dermatitis caused by Eriodictyon parryi, better known as poodle-dog bush, is a growing cause of contact dermatitis in California. Blooming after a large fire, E parryi is a threat to reforestation workers as well as countless outdoor enthusiasts across the state. This paper focuses on the epidemiology, identification, immunochemistry, pathophysiology, prevention, and treatment of contact dermatitis from this little-researched plant.
Use of Human Remains Detection Dogs for Wide Area Search After Wildfire: A New Experience for Texas Task Force 1 Search and Rescue ResourcesIn September 2011, wildfires in Bastrop County, TX, were the most destructive in the state's history, consuming more than 34 000 acres (13 759 hectares) and more than 1600 homes in the process. The wildfires began by consuming more than 30 homes across 2 miles (3.2 km) in 17 minutes, raising the fear that local residents may not have had sufficient time to escape the conflagration. Texas Task Force 1 deployed for a new mission, the search and recovery of human remains. Although there have been other larger and more widespread fires in the past, it was the speed at which this fire spread that created the environment requiring such a search.
Soft Tissue Foreign Body Removal Technique Using Portable UltrasonographyRetained foreign objects account for as much as 2% of soft tissue injuries sustained in the wilderness. Subcutaneously embedded fragments are often missed during the initial medical evaluation and may result in morbidity secondary to delayed removal. Although the utility of ultrasonography in the emergency department for the detection of retained objects is established, the potential use of point-of-care ultrasound to aid with foreign body removal in the field has not been well described. We present 2 case reports that demonstrate the value of ultrasonography in detecting and successfully removing foreign bodies sustained in the wilderness, and outline a procedural technique that minimizes morbidity and uses equipment available in wilderness medical field kits.
Ultrasound and Ski Resort Clinics: Mapping Out the Potential BenefitsSkiing and snowboarding are popular activities that involve high kinetic energies, often at altitude, and injuries are common. As a portable imaging modality, ultrasound may be a useful adjunct for mountainside clinics. This review briefly discusses skier and snowboarder injury profiles and focuses on the role of ultrasound for each injury type.
Recognizing Dangerous Snakes in the United States and Canada: A Novel 3-Step Identification MethodThe rapid and accurate recognition of dangerously venomous snakes following bites is crucial to making appropriate decisions regarding first aid, evacuation, and treatment. Past recommendations for identification of dangerous North American pit vipers have often required subjective determinations of head shape or relied on traits shared with some nondangerous species (elliptical pupils and undivided subcaudal scales). Heat-sensitive facial pits are diagnostic but require close examination of the dangerous head, and cephalic traits are useless when working with a decapitated carcass.
Infectious Diseases Associated with CavesIn recent times, caving has become increasingly popular, with almost 2 million people visiting national park caves each year in the United States. Although the 2 million tourist visits are extremely low risk, smaller numbers of sport cavers are at risk for some high risk conditions, and expedition cavers are at risk for some obscure infections. Infectious diseases like histoplasmosis, rabies, leptospirosis, and tick-borne relapsing fever may be transmitted by the underground fauna. To reduce the risk of illness or injury while caving, knowledge of potential risks before engaging in this activity is important.
Triaging Multiple Victims in an Avalanche Setting: The Avalanche Survival Optimizing Rescue Triage Algorithmic ApproachAs winter backcountry activity increases, so does exposure to avalanche danger. A complicated situation arises when multiple victims are caught in an avalanche and where medical and other rescue demands overwhelm resources in the field. These mass casualty incidents carry a high risk of morbidity and mortality, and there is no recommended approach to patient care specific to this setting other than basic first aid principles. The literature is limited with regard to triaging systems applicable to avalanche incidents.
Sensationalistic Journalism and Tales of Snakebite: Are Rattlesnakes Rapidly Evolving More Toxic Venom?Recent reports in the lay press have suggested that bites by rattlesnakes in the last several years have been more severe than those in the past. The explanation, often citing physicians, is that rattlesnakes are evolving more toxic venom, perhaps in response to anthropogenic causes. We suggest that other explanations are more parsimonious, including factors dependent on the snake and factors associated with the bite victim's response to envenomation. Although bites could become more severe from an increased proportion of bites from larger or more provoked snakes (ie, more venom injected), the venom itself evolves much too slowly to explain the severe symptoms occasionally seen.
The Anti Snake Venom Crisis in Africa: A Suggested Manufacturers Product GuideConsiderable attention has been given to the shortage of anti snake venom in Africa. The current supply is reported to rest at crisis levels, and considerable attention has been given to reporting the crisis. What has been absent is a recommended list of anti snake venoms that suppliers can produce in order to alleviate the problem. Suppliers who may want to enter the market and provide new anti snake venoms are hampered by a lack of knowledge of which to provide, where to source the venoms necessary for production, and the likely volume levels required.
Exercise-Associated Hyponatremia: Overzealous Fluid ConsumptionExercise-associated hyponatremia is hyponatremia occurring during or up to 24 hours after prolonged exertion. In its more severe form, it manifests as cerebral and pulmonary edema. There have now been multiple reports of its occurring in a wilderness setting. It can now be considered the most important medical problem of endurance exercise. The Second International Exercise-Associated Hyponatremia Consensus Conference gives an up-to-date account of the nature and management of this disease. This article reviews key information from this conference and its statement.
Antisnake Venom Production Crisis—Who Told Us It Was Uneconomic and Unsustainable?The world of antisnake venom production is currently a gloomy place to visit. It is described as being in crisis, characterized by shortages, producers leaving the market, high prices, and unsustainability. It has been reduced to a pauper-like status, doomed to relying on chari\ handouts for resolution. The worrying aspect of this is that little work has been done to establish the true economics and return on antisnake venom if provided by private companies. Fortunately, it is amenable to economic analysis, and in this manner, a rational approach to further development and distribution can be obtained.
Field Management of Displaced Ankle Fractures: Techniques for Successful ReductionAnkle fracture/dislocations are generally low-energy injuries most commonly seen in older adults. Prompt reduction is indicated when evacuation to definitive care would be prolonged or neurovascular compromise to the foot is suspected. Reduction restores neurovascular integrity, realigns joint contact surfaces, reduces pain, and decreases soft-tissue edema. The hematoma block is a safe, easy, and effective method of obtaining adequate anesthesia to allow manipulation of displaced fractures. Although most commonly used for distal radius fractures, the hematoma block has been demonstrated to be as effective as conscious sedation for ankle reduction analgesia.
The Global Snakebite Crisis—A Public Health Issue Misunderstood, Not NeglectedThe global problem of venomous snakebite continues to attract attention despite it being described as a “neglected” issue. The current focus of the World Health Organization (WHO) remains anti– snake venom quality, although “availability and sustainability” of supply are consistently described as the key issues. Sustainability of antivenom supply has been elusive, with cost and pricing in developing countries being cited as the major reasons. The current WHO approach fails to explore the cost issue, but rather focuses on quality improvements, which may well adversely affect the costs of a product already perceived to be ‘unaffordable.’ The reference to cost and price indicates a marketing-based perspective may well give more relevant solutions to the snakebite crisis.
Time for an Alternative Perspective: The Eternal Problem of Supply and Quality of Anti Snake Venom in the Developing World—“It's the Economy, Stupid”The “crisis in anti snake venom supply” has been an enduring problem. Despite the frequency with which it appears in the literature, it remains unquantified and an enigma. If there is a serious shortage of anti snake venom (ASV), why has this not been resolved? Anti snake venoms are produced, and yet many suppliers are described as leaving the market. There appears to be a problem in the call for highly effective, high-quality, and cheap anti venoms that contributes to this result of suppliers leaving the market.
The Use of Extrication Devices in Crevasse Accidents: Official Statement of the International Commission for Mountain Emergency Medicine and the Terrestrial Rescue Commission of the International Commission for Alpine Rescue Intended for Physicians, Paramedics, and Mountain RescuersInjured patients in crevasses who are suspected of having sustained spinal injuries should ideally be extricated after being immobilized in a horizontal position on a stretcher and having a cervical collar applied. Sometimes, however, horizontal stabilization is not possible, because the crevasse is too narrow, and the patient needs to be stabilized in a vertical position. In such cases an extrication device can be a useful adjunct. The Kendrick Extrication Device™ stabilizes the position of the body and maintains firm support of the head, neck, and torso.
The “Worldwide Shortage” of Antisnake Venom: Is the Only Right Answer “Produce More” Or Is It Also “Use It Smarter?”A frequent tenet of snakebite literature is what has been described as the “worldwide shortage of antisnake venom” (ASV) and the demand for greater production. Antisnake venom is the mainstay of snakebite management, and thus this principle of “shortage” can impact the view of policy makers when it comes to framing solutions to the problem. This paper presents a model to enable policy makers to assess the amount and utilization of ASV in their areas. The model assesses ASV usage according to 2 criteria: risk and wastage.
Venomous Snakebite in Mountainous Terrain: Prevention and ManagementThe prevention and management of venomous snakebite in the world's mountains present unique challenges. This paper presents a series of practical, clinically sound recommendations for management of venomous snakebite in a mountain environment. The authors performed an extensive review of current literature using search engines and manual searches. They then fused the abundant knowledge of snakebite with the realities of remote first aid and mountain rescue to develop recommendations. A summary is provided of the world's most troublesome mountain snakes and the mechanisms of toxicity from their bites.
Snakes of Medical Importance in India: Is the Concept of the “Big 4” Still Relevant and Useful?Snakebites continue to be a major medical concern in India. However, there is very little hard evidence of a numerical nature to enable us to understand which species are responsible for mortality and morbidity. For many decades, the concept of the “Big 4” Snakes of Medical Importance has reflected the view that 4 species are responsible for Indian snakebite mortality—the Indian cobra (Naja naja), the common krait (Bungarus caeruleus), the Russell's viper (Daboia russelii) and the saw-scaled viper (Echis carinatus).
The Perception of Risk and Risk Taking Behavior: Implications for Incident Prevention StrategiesCore to incident prevention strategies is the need to identify factors that influence the decision-making process linked to risk-taking behavior. Participants’ perception of risk and associated norms and practices may play a key role in relation to decisions to engage with a risk and subsequent risk-management strategies. A range of factors that influence the perception of risk and risk-taking behavior are discussed. It is proposed that prevention strategies need to be sensitive to the context of participation, the attitudes and beliefs of participants, and the motives for participation.
Venomous Adversaries: A Reference to Snake Identification, Field Safety, and Bite-Victim First Aid for Disaster-Response Personnel Deploying Into the Hurricane-Prone Regions of North AmericaEach hurricane season, emergency-preparedness deployment teams including but not limited to the Office of Force Readiness and Deployment of the US Public Health Service, Federal Emergency Management Agency, Deployment Medical Assistance Teams, Veterinary Medical Assistance Teams, and the US Army and Air Force National Guard are at risk for deploying into hurricane-stricken areas that harbor indigenous hazards, including those posed by venomous snakes. North America is home to 2 distinct families of venomous snakes: 1) Viperidae, which includes the rattlesnakes, copperheads, and cottonmouths; and 2) Elapidae, in which the only native species are the coral snakes.
Surviving Atmospheric Spacecraft BreakupSpacecraft travel higher and faster than aircraft, making breakup potentially less survivable. As with aircraft breakup, the dissipation of lethal forces via spacecraft breakup around an organism is likely to greatly increase the odds of survival. By employing a knowledge of space and aviation physiology, comparative physiology, and search-and-rescue techniques, we were able to correctly predict and execute the recovery of live animals following the breakup of the space shuttle Columbia. In this study, we make what is, to our knowledge, the first report of an animal, Caenorhabditis elegans, surviving the atmospheric breakup of the spacecraft that was supporting it and discuss both the lethal events these animals had to escape and the implications for search and rescue following spacecraft breakup.